Updated Trends and Outcomes in Autologous Breast Reconstruction in the United States, 2016-2019

INTRODUCTION

Autologous breast reconstruction (ABR) has increased in recent decades, although concerns for access remain. As such, our goal is to trend national demographics and operative characteristics of ABR in the United States.

METHODS

Using the National Inpatient Sample, 2016-2019, the International Classification of Disease , Tenth Edition codes identified adult female encounters undergoing ABR. Demographics and procedure-related characteristics were recorded. Discharge weights generated national estimates. Statistical analysis included univariate testing and multivariate regression modeling.

RESULTS

A total of 52,910 weighted encounters met the criteria (mean age, 51.5 ± 10.0 years). Autologous breast reconstruction utilization increased (Δ = +5%), 2016-2019, primarily driven by a rise in deep inferior epigastric perforator (DIEP) reconstructions (Δ = +28%; incidence rate ratio [IRR], 1.070; P < 0.001), which were predominant throughout the study period (69%). More recent surgery year, bilateral reconstruction, higher income levels, commercial insurance, and care in the South US region increased the odds of DIEP-based ABR ( P ≤ 0.036). Transverse rectus abdominis myocutaneous flaps, bilateral reconstructions, higher comorbidity levels, and experiencing complications increased the length of stay ( P ≤ 0.038). Most ABRs (75%) were privately insured. The rates of immediate reconstructions increased over the study period (from 26% to 46%; IRR, 1.223; P < 0.001), as did the rates of bilateral reconstructions (from 54% to 57%; IRR, 1.026; P = 0.030). The rates of ABRs performed at teaching hospitals remained high (90% to 93%; P = 0.242).

CONCLUSIONS

As of 2019, ABR has become more prevalent, with the DIEP flap constituting the most common modality. With the increasing ABR popularity, efforts should be made to ensure geographic and financial accessibility.

Diversity in online resources for breast reconstruction: What do patients see?

BACKGROUND

Online resources are commonly used by patients to obtain information on breast reconstruction. Despite the key role of these resources in patient decision-making, their visual content has not yet been evaluated. This study sought to 1) characterize the presence and content of visual aids in online patient education breast reconstruction resources and 2) determine if the women represented in these visual aids reflect the breast reconstruction patient population in the United States.

METHODS

The top 10 Google websites and the first 400 Google Images containing photographs/graphics depicting human skin for the search phrase "breast reconstruction" were analyzed. Images were categorized by content as "Before/After," "Surgical/Anatomical," "Step-by-Step," or "Breast-Centric Stock Images." Image subjects were classified by skin tone into "White" or "Non-White" using the Fitzpatrick scale and by body type into "Lean" or "Full-Figured."

RESULTS

In total, 471 images were analyzed. These were predominantly "Before/After" images (43.9%), followed by "Breast-Centric Stock Images" (27.4%), "Surgical/Anatomical" (24.2%), and "Step-by-Step" (4.5%). The majority of all images depicted "White" skin types (90.7%) and "Lean" body types (73.0%). "Before/After" images were more likely to show "Full-Figured" women than the other content categories (p < 0.0001) and had the highest percentage of "Non-White" skin types (35.3%).

CONCLUSIONS

Our findings demonstrate that breast reconstruction online resources are not reflective of the patient population seeking reconstruction. Improving the diversity of online image resources can both better represent our diverse patient population as well as better align patient expectations with postoperative outcomes, likely improving patient satisfaction.

Risk stratification in subpectoral to prepectoral pocket conversion to reduce post-reconstruction animation deformity

BACKGROUND

Animation deformity is a morbid complication that impacts women undergoing subpectoral implant-based breast reconstruction. Transferring implants from the subpectoral to prepectoral space, pocket conversion, can be performed to minimize this issue. While prior literature has evaluated outcomes associated with this procedure, we investigated the risk factors most commonly associated with post-conversion complications.

METHODS

We performed a retrospective cohort investigation of women undergoing prepectoral pocket conversion. Pre-conversion clinical characteristics and surgical complications (major and minor) were collected. Predictors for postoperative complications were identified using univariate and multivariate logistic regression models. Odds ratios (OR) and adjusted odds ratios (aOR) are presented with 95% confidence intervals, and p-values were assessed at α = 0.05.

RESULTS

A total of 34 patients (63 breasts) were included. Pocket conversion relieved animation deformity in all breasts. The overall rates of major and minor complications were 14.3% (n = 9/63) and 34.9% (n = 22/63), respectively, by mean follow-up of 11.1 months. After adjusting for confounders, pre-conversion implant rupture (OR= 6.00, CI= 0.99-34.58; aOR= 12.8, CI= 1.15-170.32) and duration of implant placement (OR=1.35, CI= 1.07-1.78; aOR= 1.1, CI= 1.00-1.21) were found to be significant predictors of major postoperative complications.

CONCLUSION

With a fairly inclusive patient population, this series provides data for improved risk stratification of patients considering conversion to relieve animation deformity. Interestingly, traditional risk factors (namely, body mass index and smoking status) were not significant predictors for postoperative complications, suggesting that conversion may be safe in high-risk patients. Such data support more informed preoperative counseling and wider application of this procedure.

Reintroducing Flap Reconstruction: One Institution's Safe Return to Flap Surgery during the COVID-19 Pandemic

BACKGROUND

 Prevention of nosocomial coronavirus disease 2019 (COVID-19) infection for patients undergoing flap-based reconstructive surgery is crucial to providing care and maintaining operative volume and income to support plastic surgery programs. We conducted this study to (1) determine the postoperative incidence of COVID-19 among patients undergoing flap reconstruction from December 1, 2019 to November 1, 2020 and (2) compare 30-day outcomes between patients who underwent surgery before and during the early pandemic.

METHODS

 We conducted an 11-month retrospective cohort study of all patients who underwent flap reconstruction across our institution. We abstracted patient demographics, intraoperative management, COVID-19 testing history, and 30-day postoperative complications from electronic health records. Nosocomial COVID-19 infection was defined as reverse transcription polymerase chain reaction (RT-PCR) viral ribonucleic acid detection within 30 days of patients' postoperative course or during initial surgical admission. We used chi-squared tests to compare postoperative outcomes between patients who underwent surgery before (prior to March 12, 2021, when our institution admitted its first COVID-19 patient) versus during (on/after March 12, 2021) the pandemic.

RESULTS

 Among the 220 patients (mean [standard deviation] age = 53.8 [18.1] years; female = 54.8%) who underwent flap reconstruction, none had nosocomial COVID-19 infection. Five (2%) patients eventually tested COVID-19 positive (median time from surgery to diagnosis: 9 months, range: 1.5-11 months) with one developing partial flap loss while infected. Between patients who underwent free flap surgery before and during the pandemic, there were no significant differences in 30-day takebacks (15.6% vs. 16.6%, respectively; p > 0.999), readmissions (9.4% vs. 12.6%, respectively; p = 0.53), and surgical complications (e.g., total flap loss 1.6% vs. 2.1%, p = 0.81).

CONCLUSION

 Robust precautions can ensure the safety of patients undergoing flap surgeries across an academic medical institution, even during periods of high COVID-19 admission rates. Further studies are needed to generate evidence-based guidelines that optimize infection control and flap survival for patients undergoing reconstruction.

Transversus abdominus plane blocks do not reduce rates of postoperative prolonged opioid use following abdominally based autologous breast reconstruction: a nationwide longitudinal analysis

Background

The transversus abdominus plane (TAP) block reduces postoperative donor site pain in patients undergoing autologous breast reconstruction with an abdominally based flap. This study aimed to determine the effect of TAP blocks on rates of conversion to chronic opioid use.

Methods

The Clinformatics Data Mart was queried from 2003 to 2019, extracting adult encounters for abdominally based free and pedicled flaps based on common procedural terminology (CPT) codes. Patients were excluded if they had filled a narcotic prescription 1 year to 30 days prior to surgery. The exposure variable-TAP block-was identified by CPT codes. Outcomes were evaluated using morphine milligram equivalents (MME) from prescriptions filled between 30 days prior to and 30 days after surgery. Chronic opioid use (COU) was defined as receiving 4 unique prescriptions or a 60-day supply between 30 and 180 days after surgery.

Results

Of the 4091 patients, (mean age 51.2 ± 9.0 years), 181 (4.4%) had a TAP block placed. Perioperative MMEs/day, postoperative COU, and length of stay did not differ in patients who received a TAP block (p = 0.142; p = 0.271). Significant predictors of risk of conversion to COU included younger age, pedicled abdominal flap, Elixhauser comorbidity index score > 3, filling a psychiatric medication prescription, and filling a benzodiazepine prescription.

Conclusions

In patients undergoing autologous breast reconstruction with abdominally based flap reconstruction, TAP blocks do not decrease perioperative MME/day, conversion to chronic opioid use, or length of stay. These data suggest that intraoperative TAP block placement may be a low-yield opioid-reduction strategy.Level of evidence: Level III, risk/prognostic study.

Predictors of Mortality and Amputation in Patients With Necrotizing Soft Tissue Infections of the Upper Extremity

PURPOSE

Necrotizing soft tissue infection (NSTI) of the upper extremity is characterized by rapid progression, local tissue necrosis, systemic toxicity, and a high mortality rate. The negative consequences of debridement are balanced against preservation of life and limb. The primary objective of this study was to identify predictors of mortality in upper extremity NSTI. Secondary objectives were to identify predictors of amputation, final defect size, length of stay, and readmission within 30 days.

METHODS

An institutional registry for patients with NSTI was retrospectively queried from a single tertiary center covering a large referral population. Data on confirmed upper extremity NSTI were used to determine patient characteristics, infection data, and operative factors. Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Quick Sequential Organ Failure Assessment (qSOFA) scores were calculated from primary data to provide a measure of clinical severity. Bivariate screening identifying possible predictors of mortality and multivariable regression was performed to control for confounding. Similar analyses were performed for amputation, final defect size, and readmission within 30 days.

RESULTS

A total of 99 patients met the study criteria. In-hospital mortality occurred in 12 patients, and amputation was performed in 7 patients. Etiology, causative organism, and clinical severity scores were variable. Logistic regression showed mortality to be independently predicted by vasopressor dependency outside of operative anesthesia. The relatively low number of case events, limited sample size, and multiple comparisons limited the evaluation of lesser predictor variables. The LRINEC score did not strongly predict amputation or death in this series.

CONCLUSIONS

Necrotizing soft tissue infection of the upper extremity carries risk of mortality and amputation, and effective treatment requires prompt recognition, early goal-directed resuscitation, and early debridement. The strongest independent predictor of in-hospital mortality was vasopressor dependence outside operative anesthesia. The LRINEC score did not strongly predict death or amputation in upper extremity NSTI.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Prepectoral breast reconstruction is safe in the setting of post-mastectomy radiation therapy

BACKGROUND

Many breast reconstruction patients undergo post-mastectomy radiation therapy (PMRT), which is well known to increase the risk of complications. There is limited data on outcomes and safety of prepectoral breast reconstruction in this setting. The purpose of this study was to compare the outcomes of prepectoral versus subpectoral two-stage breast reconstruction in patients undergoing PMRT.

METHODS

We conducted a retrospective cohort study of two-stage breast reconstructions performed at our institution during a 22-month period. Patients who received PMRT were identified, and two cohorts were created: those who underwent prepectoral versus subpectoral reconstruction. We collected data including patient characteristics, operative variables, and clinical outcomes. Bivariate analyses and multivariable logistic regressions were conducted.

RESULTS

We captured 313 patients (492 breasts) that had undergone two-stage reconstruction. A total of 69 breasts received PMRT; 28 were reconstructed prepectorally, and 41 breasts subpectorally. The two cohorts were well matched. We detected no differences in clinical outcomes between the two groups after a median follow-up time of 24 months. There, however, were differences in perioperative variables. Prepectoral reconstruction was associated with a shorter operative time, shorter length of hospital stay, higher cost, and shorter time to final reconstruction. Multivariable logistic regression demonstrated that prepectoral reconstruction is not an independent predictor of adverse events.

CONCLUSIONS

Although radiation is a known risk factor for many complications following breast reconstruction, prepectoral device placement is safe in this high-risk population. Although the rate of capsular contracture is reported to be higher in the general prepectoral population, this was not found in our radiated prepectoral population.

Single Institution's Plastic Surgery Case Trends and Considerations in the Midst of COVID-19

Supplemental Digital Content is available in the text.

Diagnostic and Therapeutic Use of Botox for Breast Reconstruction

INTRODUCTION

Breast reconstruction is most commonly performed using implant-based reconstruction. Patients with subpectoral implant placement with or without latissimus dorsi (LD) muscle coverage can experience muscle pain and animation deformity. Due to minimal literature describing the use of botulinum toxin (BTX-A) treatment for these side effects from implant-based reconstruction, we report our outcomes.

METHODS

A retrospective chart review of breast reconstructive patients for a single surgeon was performed. Patients who underwent BTX-A injection for muscular pain, spasm, or animation deformity were identified and outcomes reviewed. They were also stratified based on radiation treatment and type of muscle flap used.

RESULTS

Eleven patients were identified who had a submuscular pectoralis pocket and/or a pedicled latissimus dorsi flap. Nineteen breasts were treated. The average amount of time from the patient's last surgery to BTX-A injection was 11.2 months. 25-100 units were used per injection with an average of 60 units. Non-irradiated patients had signifycantly lower post-injection capsular contracture Baker grades and significantly lower amounts of BTX-A were injected. Patients who had both pectoralis major muscle and LD implant-reconstruction were significantly less likely to have improvement in pain/tightness. Most patients reported improvement or resolution of their pain and/or animation deformities.

CONCLUSION

Implant-based reconstruction using the pectoralis major and/or LD muscles can be plagued with muscular pain, spasm, and animation deformities. The use of BTX-A is a diagnostic and therapeutic modality for these post-breast reconstruction patients with most patients having resolution of symptoms without the need for additional surgery.

Recognizing the Vulnerable: Perspectives, Attitudes, and Interests of Women With Uterine Factor Infertility Towards Uterus Allotransplantation

BACKGROUND

Uterine allotransplantation (UTx) is a novel therapy to allow women with uterine factor infertility (UFI) to bear their own children. To date, over 60 UTx have been performed, resulting in 15 live births. Our study investigates the attitudes, perspectives, and interests of women with UFI towards UTx.

METHODS

Anonymous questionnaires were distributed electronically to women diagnosed with UFI at Johns Hopkins Hospital between the years 2003 and 2018.

RESULTS

Thirty-one women with UFI were identified, resulting in 10 completed surveys. The average age was 31.7 ± 6.31 years, and the average age of diagnosis was 20 years (range 14-31); all 10 surveyed women had congenital UFI. Of note, 80% of women agreed that UTx should be an option for women with UFI, and 90% would consider receiving a UTx. The majority of the nine (90%) women who had previously heard of UTx learned about it from the news (5, 50%). When asked to rank the risks related to UTx in order of personal importance, only two women ranked themselves most important; the other woman ranked fetus and donor as more important. All women had health insurance (70% had private insurance), and 90% believed that UTx should be covered by health insurance.

CONCLUSIONS

We surveyed women with UFI and found that the majority are willing to have UTx, despite the associated risks of the procedure. Taking into consideration the responses for ranking the importance of risks of the procedure, women with UFI should be considered a vulnerable population, requiring special considerations for UTx informed consents.

A New Decade for Diversity: Trends in Representation of Women at the Northeastern Society of Plastic Surgeons

BACKGROUND

In 2018, the Northeastern Society of Plastic Surgeons first Women in Plastic Surgery was established, reflecting the national trend to address the gender gap between men and women in surgery. Conferences, such as the annual NESPS, are important opportunities to increase visibility of female role models and resources to address deterrents to surgical careers. We thus sought to examine the participation and visibility of women in the NESPS over the last decade.

METHODS

Abstracts and programs from the NESPS regional conferences between 2013 and 2019 were accessed via the publicly available past meetings archives, and registration lists were provided by the NESPS. Registrants, panelists, speakers, moderators, and first author and senior author listed for each poster presentation, podium presentation was listed, sex was determined (male or female), and sex were aggregated by category of participation. Significance was set at a P value of less than 0.05.

RESULTS

Registration of women for the NESPS annual conferences was constant for 5 years (2013-2017), followed by an increase in female registrants from 27.1% in 2017 to 42.3% in 2019. Female representation among poster and podium presentations also increased from 2017 to 2019 (7.7%-23.3% poster presentations and 11.1%-23.4% podium presentations). Invited positions (speakers, panelists, and moderators) had a peak of 32.2% in 2017, but otherwise, there is no clear evidence of improved representation of women.

CONCLUSIONS

We found an increase in the proportion of female registrants at the annual NESPS conferences from 2013 to 2019. However, visibility of female participants fluctuated over the same period; addressing this represents one opportunity for closing the gender gap at the NESPS. As the percentage of female trainees continues to rise, we look to female faculty to continue to participate in educational events, such as the NESPS meeting, and to be present as role models for the growing new generation of female plastic surgeons.

Staged Approach to Autologous Reconstruction in the Ptotic Breast: A Comparative Study

BACKGROUND

Nipple-sparing mastectomy (NSM) and autologous breast reconstruction are associated with higher patient satisfaction, quality of life, and aesthetic outcome. For patients with naturally ptotic breasts, this ideal reconstructive treatment of NSM and autologous breast reconstruction poses a challenge. We describe our experience in treating patients with ptotic natural breasts using a 2-staged approach: oncoplastic breast reduction in the first stage followed by nipple-sparing mastectomy and immediate autologous reconstruction in a second stage.

METHODS

We reviewed cases of patients with grade III ptosis who underwent a staged reconstruction approach with reduction mammaplasty followed by NSM and immediate reconstruction with an abdominally based free flap (2014-2019). We compared this group of patients to a second group who underwent staging with a technique of nipple-areola complex (NAC) devascularization. A survey was administered to assess for patient satisfaction and aesthetic outcome 1 year after the second stage procedure.

RESULTS

Eight patients were identified in our reduction group, and 9 patients were identified in our devascularization group. No cases of total NAC necrosis were noted in either group (0%). Two cases of partial NAC necrosis were noted in the devascularization group (11%), whereas none were observed in the reduction group. All patients were satisfied with final outcome (100%, P = 1.0). Aesthetic scores across all factors were higher in the reduction group. Scores for overall outcome (4.6 vs 3.7, P = 0.04), natural appearance (4.8 vs 3.8, P = 0.01), breast contour (4.8 vs 3.2, P = 0.002), and position of breasts (5.0 vs 3.9, P = 0.03) were significantly higher in the reduction group.

CONCLUSIONS

Breast ptosis no longer represents a contraindication for patients desiring nipple-sparing mastectomy and immediate autologous reconstruction. This series supports the use of a 2-staged approach with reduction mammaplasty in patients with naturally ptotic breasts. A staged reduction approach may offer fewer NAC complications while also allowing for superior aesthetic outcomes.

Reconstructive and restorative cues improve public perception on the value of plastic and reconstructive surgeries

BACKGROUND

Persistent public misconceptions of plastic and reconstructive surgery (PRS), ambiguity between cosmetic versus reconstructive surgical procedures, and subjective interpretation of aesthetics can result in undervaluing of the field. Our study analyzes how patient context (cosmetic or reconstructive/restorative cues) affect public perception of outcomes and value of surgery.

METHODS

We distributed Qualtrics™ surveys to laypersons via Amazon Mechanical Turk. Demographics were self-reported. The survey presented a series of pre- and post-operative photographs of PRS surgeries alongside either a cosmetic or reconstructive/restorative cue, followed by questions on values of procedure. Survey responses were analyzed using two-tailed Student's t tests and chi square analyses, univariate and multivariate analysis, and linear regression.

RESULTS

Of the 459 respondents, the mean age was 38.5 ± 12.1 years, and was 50.5% (232) male. The majority of respondents classified breast reconstruction as a cosmetic surgery (243, 66.8%), and was rated more attractive (p < 0.0005), higher impact on self-esteem (p < 0.001), and to be covered by health insurance (p < 0.0001) compared to breast augmentation. Reconstructive cued breast and facial procedures were viewed more favorably; the exception was gynecomastia reduction. Reconstructive classification had significant positive correlation with support for insurance coverage (R² = 0.8268) and willingness to pursue (R² = 0.5328).

CONCLUSIONS

This study revealed more public support for reconstructive/restorative cued PRS cases over cosmetic cued PRS cases, and persistent misconceptions of breast reconstruction as a cosmetic procedure. Reconstructive or restorative cues can be used to educate the public and address skewed perceptions on the roles and value of PRS.

The Negative Impact of COVID-19 on Medical Education amongst Medical Students Interested in Plastic Surgery: A Cross-sectional Survey Study

Background:

The COVID-19 pandemic has resulted in unpreceded changes to medical education. Medical students interested in urology and neurosurgery have reported concerns regarding COVID-19’s effects on clinical experience and the residency application process; however, the impact amongst students interested in plastic surgery is unknown. We hypothesized that students applying into plastic surgery may experience much distress as a result of the COVID-19 pandemic.

Methods:

An electronic survey was developed by 3 plastic surgery residents and 2 academic plastic surgeons and later refined by 4 fourth-year medical students. Questions focused on medical education curricular changes, perceived impact on medical education, and demographics. From April–May 2020 the survey was distributed to medical students who were interested in plastic surgery. Participants were identified through plastic surgery residency program personnel and social media platforms.

Results: In total,

130 of the 140 respondents reported interest in plastic surgery careers. An estimated 67% were in their clinical years or completing research year(s) before residency applications. Of the respondents, 80% believed that the COVID-19 pandemic had a negative impact on their medical education. Clinical-level students compared with preclinical-level students, and students applying to residency during the 2020–2021 match cycle compared with students not applying during the 2020–2021 match cycle were significantly more likely to perceive the COVID-19 pandemic as having a negative impact on their medical education (P = 0.04 and 0.03, respectively).

Conclusion:

Medical students interested in plastic surgery perceive the COVID-19 pandemic as having a negative impact on their education, likely due to a reduction in clinical exposure.

Efficacy of a Novel Intraoperative Engineered Sharps Injury Prevention Device: Pilot Usability and Efficacy Trial

Background

The American College of Surgeons reports 88,320 intraoperative needlestick injuries (NSIs) per year, resulting in US $376 to US $2456 in costs per NSI. Engineered sharps injury prevention (ESIP) devices protect against NSIs. To our knowledge, no study has been published to date to demonstrate clinical effectiveness of an intraoperative ESIP device. Operative Armour is a wearable arm cuff that can be donned during surgical closure to allow surgeons to keep a suture pack and sharps protection container on their forearm.

Objective

We characterize Operative Armour’s ESIP device effectiveness in a tertiary hospital, hypothesizing that this device will decrease NSI risk by decreasing behaviors associated with NSIs: needle passing and handling.

Methods

A prospective case-control study was conducted with institutional review board quality improvement designation in which authors observed skin closures of plastic surgery procedures. To ensure accuracy, one surgeon was observed at a time. Control surgeries were purely observational; intervention cases involved surgeon use of the device during skin closure. Outcomes of interest included needle passing, needle handling, lost needles, and loaded waiting needles.

Results

Surgeons were observed in 50 control and 50 intervention cases. Operative Armour eliminated needle passing during skin closure. One NSI occurred in one control case; no NSIs were observed in intervention cases (P=.36). The mean number of loaded and unprotected waiting needles was also significantly decreased in the intervention group from 2.3 to 0.2 (P<.001). Furthermore, a multivariable linear regression established that Operative Armour significantly decreased the number of needle adjustments by hand per stitch observed (F_{4, 21.68}=3.72; P=.01). In fact, needle adjustments by hand decreased overall (1 adjustment per 10 stitches vs 1 adjustment per 5 stitches, P=.004), and adjustments occurred half as frequently with use of Operative Armour in free flap reconstruction (1 adjustment per 10 stitches vs 1 adjustment per 5 stitches, P=.03) and a quarter as frequently in other breast reconstruction cases such as mastopexy (1 adjustment per 20 stitches vs 1 adjustment per 5 stitches, P=.002).

Conclusions

Operative Armour effectively functions as an ESIP device by decreasing intraoperative needle passing and handling. Although sample size prohibits demonstrating a decrease in NSIs during observed cases, by decreasing behaviors that drive NSI risk, we anticipate an associated decrease in NSIs with use of the device.

Nutrition Support After Cardiac Surgery: Lessons Learned From a Prospective Study

The importance of postoperative nutrition support (NS) has been poorly recognized in cardiac surgery. In this population, we aim to describe the delivery of NS, factors affecting calorie/protein delivery and NS-associated morbidity. From January 2015 to January 2017, we prospectively observed all cardiac surgery patients at a single institution who could not take nutrition orally, requiring postoperative NS, either enteral or parenteral, for the duration of NS up to 14 days. We compared outcomes to patients without NS and examined NS indications, factors affecting its delivery and its associated complications. Nine percent of patients (232/2603) required NS for a total of 1938 NS-days. The most common indication was mechanical ventilation. NS met 69% of daily caloric needs. On days when tube feeds (TFs) were held (mean of 13 hours), this decreased to 43%, compared to 96% when TFs were not held (P < 0.001). The most common reason for holding TFs was procedures. When TFs were supplemented with parenteral nutrition (TFs + PN), 86% of daily caloric needs were met. Even on days when TFs were held, this only dropped to 77% (TFs + PN), compared to 36% (TFs-only). By multivariable logistic regression, elemental and semielemental formulas, TF volume, and postpyloric feeds increased the risk of diarrhea, occurring in 28% of patients and 18% of TF-days. In cardiac surgery patients given postoperative NS, mortality and morbidity were an order of magnitude higher than those able to be fed orally. Enteral feeding delivered approximately two-thirds of needs, but PN supplementation dramatically improved this. Diarrhea was common, associated with the postpyloric route, increasing TF volume, and nonintact formula.

Different degradation rates of nanofiber vascular grafts in small and large animal models

Nanofiber vascular grafts have been shown to create neovessels made of autologous tissue, by in vivo scaffold biodegradation over time. However, many studies on graft materials and biodegradation have been conducted in vitro or in small animal models, instead of large animal models, which demonstrate different degradation profiles. In this study, we compared the degradation profiles of nanofiber vascular grafts in a rat model and a sheep model, while controlling for the type of graft material, the duration of implantation, fabrication method, type of circulation (arterial/venous), and type of surgery (interposition graft). We found that there was significantly less remaining scaffold (i.e., faster degradation) in nanofiber vascular grafts implanted in the sheep model compared with the rat model, in both the arterial and the venous circulations, at 6 months postimplantation. In addition, there was more extracellular matrix deposition, more elastin formation, more mature collagen, and no calcification in the sheep model compared with the rat model. In conclusion, studies comparing degradation of vascular grafts in large and small animal models remain limited. For clinical translation of nanofiber vascular grafts, it is important to understand these differences.

Feasibility and perception of a question prompt list in outpatient cancer care

Introduction

Management of cancer is often characterized by difficult decisions. The National Coalition for Cancer Survivorship (NCCS) has developed the “Know Yourself” tool, a question prompt list (QPL) to enable patients to participate in these decisions.

Methods

We investigated the feasibility of using the NCCS tool by oncologists and their patients with cancer in a before-and-after pilot study at a tertiary medical center. We also measured patient reported decision preparedness, anxiety, satisfaction with care, trust in physician, discussion of care with their primary care physician (PCP), and general state of health, and solicited feedback from clinicians and patients on use of the form.

Results

Ninety patients and fifteen clinicians participated. Most patients reported the Tool was easy to use (91%) and would recommend it to others (73%) however fewer reported discussing the Tool at the visit (31%) or felt that it improved the quality of care (45%) or communication with the oncologist (56%). Clinicians reported Tool use in only 16 of 60 visits (27%); in these visits the Tool was helpful in identifying areas of concern (74%), guiding the clinical interaction (67%), promoting communication (62%), identifying areas of need (70%), and improving quality of care (71%). Decision preparedness, trust in physicians, uncertainty about care, anxiety, patient satisfaction and discussion of care with the PCP was unchanged with Tool use compared to non-use.

Conclusions

The Know Yourself tool had poor uptake but was favorably received among both patients and clinicians who used it. These findings suggest some patients could benefit from QPLs. Future work should test how implementation strategies might achieve greater use.

An unusual etiology of hyperparathyroidism: robotic-assisted resection of a giant functional intrathymic parathyroid cyst

Parathyroid cysts (PCs) are relatively rare entities, with an even smaller proportion that functionally produce parathyroid hormone (PTH). Given associated hypercalcemia, often symptomatic, as well as potentially related osteoporosis and/or nephrolithiasis, resection of these functional cysts is often indicated. This case report details the management course for a patient who presented with primary hyperparathyroidism and was ultimately found to have a functional intrathymic PC. During initial workup, 4-dimensional computed tomography (4D-CT) of the neck demonstrated enlarged left upper and right lower parathyroid glands; however, the patient's hyperparathyroid state persisted even after bilateral neck exploration and resection of these two glands. Subsequent postoperative imaging of the mediastinum revealed a large (11 cm) thymic cyst. The patient consequently underwent uneventful robotic-assisted thoracoscopic excision of the mediastinal cyst. Intraoperative blood PTH levels dropped from 734 pg/mL preoperatively to 86 pg/nL 10 minutes following resection, consistent with surgical cure by the Miami Criteria. At two months postoperatively, the patient's serum total calcium (STC) was normal at 9.2 mg/dL. Final surgical pathology noted a 15-gram parathyroid gland, with cystic degeneration. As the robot becomes further integrated into the everyday practice of thoracic surgery, we believe this approach offers advantages over conventional video-assisted thoracoscopic surgery (VATS) for mediastinal resections. Advantages include better visualization and finer, more precise dissection, especially important in this case, given the proximity of vital structures and the small, but real, risk of parathyromatosis associated with intraoperative cyst rupture.

Virtual Reality in Neurointervention

OBJECTIVES

Virtual reality (VR) allows users to experience realistic, immersive 3D virtual environments with the depth perception and binocular field of view of real 3D settings. Newer VR technology has now allowed for interaction with 3D objects within these virtual environments through the use of VR controllers. This technical note describes our preliminary experience with VR as an adjunct tool to traditional angiographic imaging in the preprocedural workup of a patient with a complex pseudoaneurysm.

METHODS

Angiographic MRI data was imported and segmented to create 3D meshes of bilateral carotid vasculature. The 3D meshes were then projected into VR space, allowing the operator to inspect the carotid vasculature using a 3D VR headset as well as interact with the pseudoaneurysm (handling, rotation, magnification, and sectioning) using two VR controllers.

RESULTS

3D segmentation of a complex pseudoaneurysm in the distal cervical segment of the right internal carotid artery was successfully performed and projected into VR. Conventional and VR visualization modes were equally effective in identifying and classifying the pathology. VR visualization allowed the operators to manipulate the dataset to achieve a greater understanding of the anatomy of the parent vessel, the angioarchitecture of the pseudoaneurysm, and the surface contours of all visualized structures.

CONCLUSION

This preliminary study demonstrates the feasibility of utilizing VR for preprocedural evaluation in patients with anatomically complex neurovascular disorders. This novel visualization approach may serve as a valuable adjunct tool in deciding patient-specific treatment plans and selection of devices prior to intervention.

3D bioprinting using stem cells

Recent advances have allowed for three-dimensional (3D) printing technologies to be applied to biocompatible materials, cells and supporting components, creating a field of 3D bioprinting that holds great promise for artificial organ printing and regenerative medicine. At the same time, stem cells, such as human induced pluripotent stem cells, have driven a paradigm shift in tissue regeneration and the modeling of human disease, and represent an unlimited cell source for tissue regeneration and the study of human disease. The ability to reprogram patient-specific cells holds the promise of an enhanced understanding of disease mechanisms and phenotypic variability. 3D bioprinting has been successfully performed using multiple stem cell types of different lineages and potency. The type of 3D bioprinting employed ranged from microextrusion bioprinting, inkjet bioprinting, laser-assisted bioprinting, to newer technologies such as scaffold-free spheroid-based bioprinting. This review discusses the current advances, applications, limitations and future of 3D bioprinting using stem cells, by organ systems.

Use and usefulness of the “know yourself” tool in outpatient cancer care

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Background: Patient-physician communication is important to cancer care. The National Coalition for Cancer Survivorship developed the Know Yourself Tool, a 2-page form, to improve patients’ understanding of goals of care and clinicians’ understanding of patients’ priorities/expectations. We assessed the Tool’s use and usefulness. Methods: This mixed-methods study at an academic cancer center recruited 1 medical, 1 radiation, and 1 surgical oncologist for each of 5 cancer types: breast, lung, gastrointestinal, genitourinary, head & neck. For each clinician (n = 15), we recruited 2 control patients to observe usual care (n = 30) and then 4 intervention patients who were provided the Tool (n = 60); eligible patients were at a decision point in their care. Data were collected for the decision making visit via patient and physician post-visit surveys analyzed descriptively and visit recordings/transcripts to analyze: 1) option presentation 2) patient preference assessment 3) shared decision making elements 4) patient question asking opportunities. Results: Of 90 patients, 39 (43%) were female and 75 (83%) were white. Of the 60 intervention patients, 42 (70%) completed a post-visit survey: 15 (36% of respondents) reported using the Tool and 13 (31%) discussing the Tool. Nearly half (49%) reported the Tool helped them prepare for follow-up visits and know the importance of their perspective in decision making. Patients reported the Tool was easy to use (76%) and would recommend the Tool to others (52%). Clinicians reported on Tool use for 24 visits, finding it most helpful in identifying areas of concern (74%). Based on visit transcripts, physicians were more likely to describe certain options as more appropriate than others with intervention vs control patients. However, physicians were less likely to assess patient preference, engage in shared decision making behaviors, and provide opportunities for patients to ask questions with intervention vs control patients. Conclusions: Use and usefulness of the Know Yourself Tool was limited. Further work should identify barriers to Tool use, determine if there are specific subgroups for whom the Tool would be more useful, and further elucidate how the Tool affects patient-clinician interactions.

Cutaneous squamous cell cancer (cSCC) risk and the human leukocyte antigen (HLA) system

Cutaneous squamous cell carcinoma (cSCC) is the second most common cancer among Caucasians in the United States, with rising incidence over the past decade. Treatment for non-melanoma skin cancer, including cSCC, in the United States was estimated to cost $4.8 billion in 2014. Thus, an understanding of cSCC pathogenesis could have important public health implications. Immune function impacts cSCC risk, given that cSCC incidence rates are substantially higher in patients with compromised immune systems. We report a systematic review of published associations between cSCC risk and the human leukocyte antigen (HLA) system. This review includes studies that analyze germline class I and class II HLA allelic variation as well as HLA cell-surface protein expression levels associated with cSCC risk. We propose biological mechanisms for these HLA-cSCC associations based on known mechanisms of HLA involvement in other diseases. The review suggests that immunity regulates the development of cSCC and that HLA-cSCC associations differ between immunocompetent and immunosuppressed patients. This difference may reflect the presence of viral co-factors that affect tumorigenesis in immunosuppressed patients. Finally, we highlight limitations in the literature on HLA-cSCC associations, and suggest directions for future research aimed at understanding, preventing and treating cSCC.

Abstract 1324: Enhancing therapeutic efficacy of albumin bound paclitaxel in breast cancer liver metastasis by homing to tumor associated macrophages: In vitro, in vivo and in silico studies

This study is aimed to evaluate and enhance the albumin-bound paclitaxel (nab-PTX) in multistage vector (MSV) for liver metastasis treatment using in silico modeling based on in vitro data, and verified via in vivo study. The resulting model will help for therapy optimization in the clinical setting.

Clinically, breast cancer liver metastases can be observed as hypoattenuated in MRI and CT images caused by low penetration of drugs or contrast agents into the lesions along with a high washout rate, which correlates to poor chemotherapeutic response. Nab-PTX is clinically used for treatment of advanced breast tumors, but not for liver metastasis. We designed MSV-nab-PTX, a new nab-PTX delivery system for specifically homing to tumor associated macrophages in the liver. MSV-nab-PTX consists of nab-PTX loaded in porous silicon multistage nanovectors which were previously shown to be efficient in delivering siRNA and other therapeutics. MSV-nab-PTX was evaluated in in vitro, in vivo and in silico models of liver metastasis. Co-culture of breast cancer tumor cells (3D-spheroids) and macrophages was developed and utilized to evaluate the drug efficacy and to study the mechanism of nab-PTX transport. Addition of macrophages in the 3D model significantly increased the efficacy of MSV-nab-PTX, but not nab-PTX, revealing the major role of macrophages in the drug transport into the lesion. Primary mouse and human macrophages were shown to uptake up to 10 ng of PTX/cell in MSV-nab-PTX with no significant effects on their viability, and later release the PTX over 24h. Treatment with MSV-nab-PTX increased chemokine production by tumor cells when compared to nab-PTX, increasing macrophage migration into the tumor sphere by more than 2-fold. Based on these data, we implemented a mathematical model linking drug release and retention from macrophages to project MSV-nAb-PTX efficacy based on the presence of macrophages in tumor biopsies. Simulation of repeat treatment every 3 days showed a significant reduction of tumor size, and was verified by the in vivo data. MSV-nab-PTX as compared to nab-PTX enhanced PTX concentration in the target lesions, increased apoptosis rate and reduced cancer cells proliferation rate, ultimately reducing the tumor size and prolonging the survival of treated mice.

This showed that MSV association with macrophages can increase drug efficacy compared to bolus injection, and that it is feasible to reach sustained lesion regression with the macromolecule-bound formulation. The in silico simulations also revealed that the timing interval is crucial for the treatment strategy, and the effect depends on the size and vascularization stage of the lesion. We conclude that an integrated in vitro, in vivo, and in silico framework may be of use to assess response to albumin bound paclitaxel targeted to breast cancer liver metastasis via tumor associated macrophages.

Citation Format: Fransisca Leonard, Curtis T. Louis, Pooja Yesantharao, Tomonori Tanei, Jenolyn F. Alexander, Liu Xuewu, Ferrari Mauro, Kenji Yokoi, Hermann B. Frieboes, Biana Godin. Enhancing therapeutic efficacy of albumin bound paclitaxel in breast cancer liver metastasis by homing to tumor associated macrophages: In vitro, in vivo and in silico studies. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1324.

Enhanced performance of macrophage-encapsulated nanoparticle albumin-bound-paclitaxel in hypo-perfused cancer lesions

Hypovascularization in tumors such as liver metastases originating from breast and other organs correlates with poor chemotherapeutic response and higher mortality. Poor prognosis is linked to impaired transport of both low- and high-molecular weight drugs into the lesions and to high washout rate. Nanoparticle albumin-bound-paclitaxel (nAb-PTX) has demonstrated benefits in clinical trials when compared to paclitaxel and docetaxel. However, its therapeutic efficacy for breast cancer liver metastasis is disappointing. As macrophages are the most abundant cells in the liver tumor microenvironment, we design a multistage system employing macrophages to deliver drugs into hypovascularized metastatic lesions, and perform in vitro, in vivo, and in silico evaluation. The system encapsulates nAb-PTX into nanoporous biocompatible and biodegradable multistage vectors (MSV), thus promoting nAb-PTX retention in macrophages. We develop a 3D in vitro model to simulate clinically observed hypo-perfused tumor lesions surrounded by macrophages. This model enables evaluation of nAb-PTX and MSV-nab PTX efficacy as a function of transport barriers. Addition of macrophages to this system significantly increases MSV-nAb-PTX efficacy, revealing the role of macrophages in drug transport. In the in vivo model, a significant increase in macrophage number, as compared to unaffected liver, is observed in mice, confirming the in vitro findings. Further, a mathematical model linking drug release and retention from macrophages is implemented to project MSV-nAb-PTX efficacy in a clinical setting. Based on macrophage presence detected via liver tumor imaging and biopsy, the proposed experimental/computational approach could enable prediction of MSV-nab PTX performance to treat metastatic cancer in the liver.